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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> co -L-1 l <br /> OWNER/OPERATOR <br /> Brad Goehring, Berghill, LLC, et. al CHECK if BILLING ADDRESSx❑ <br /> FACILITY NAME Harney Lane Property <br /> SITE ADDR S <br /> 0745 & 23649 E' Harney Ln. T Lodi 95240 <br /> Street Number I Direction I ame city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 739 <br /> Street Number Street Name <br /> CITY Linden STATE CA z'P 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 609-8280 067-040-01 & -09 pA-Z000tu76M5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS 407 W. Oak St. FAx# <br /> ( ) <br /> CITY Lodi STATE CA Z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I� DATE: l0 ` I Z- ?-Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 C OIA;nJ I E'h-K.r- <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: SAS. ®�" C '��O <br /> �V J✓ <br /> Tq1��Y <br /> M <br /> ACCEPTED BY: L L' EMPLOYEE#: DATE: <br /> ASSIGNED TO: J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 02I�0'y <br /> Fee Amount: ��� Amount Paid D Payment Date ' Z Z U <br /> Payment Type11E] Invoice# Check#• Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />